Laboratories dreading the next round of PAMA private payer data reporting may see some administrative relief if a recent MedPAC proposal aimed at reducing the reporting burden is adopted by CMS.
One of the alternatives being explored by the federal advisory body is to survey a sample of labs for their payer data, as opposed to requiring data from all labs who meet CMS’s “applicable labs” definition. As part of that proposal, Congress asked MedPAC to provide a report on the least burdensome reporting process to create a representative sample of payer rates across all market segments.
Originally put into effect in 2017, the Protecting Access to Medicare Act (PAMA) requires labs who met certain CMS volume and payment thresholds to report their private payer data to CMS in an effort to bring the Clinical Laboratory Fee Schedule (CLFS) in line with market rates. Tests could be reduced by no more than 10 percent annually for the program’s first three years, with reductions set to cap at 15 percent between 2022-2025 (although scheduled rate reductions have occasionally been frozen for various reasons).
CMS defines an applicable lab as one that bills Medicare Part B under its own NPI and collects more than 50 percent of its Medicare revenue during the data collection period under the CLFS or Medicare Physician Fee Schedule and receives at least $12,500 in CLFS revenue during the data collection period. Hospital outreach labs are included if they meet the volume thresholds and bill Part B on a CMS-1450 under type of bill (TOB) 14x.
Initially, the next round of reporting for payer data collected between January and June 2019 was supposed to take place during the first quarter of 2020. However, legislative and public health emergency-related delays pushed the next round of reporting back two years. Between January and March 2022, labs are required to report data collected between January and June 2019.
Whether this next round of reporting will be as extensive as the first continues to be discussed. A third-party contractor hired by MedPAC to analyze ways to reduce the reporting burden explored different survey methodologies that could be used to collect representative and statistically valid samples of independent, hospital outpatient, and physician office laboratories. MedPAC said it focused on these three types of labs because they furnished “nearly all” laboratory tests from the CLFS, and the prices they received varied.
The study concluded a survey could potentially reduce the number of labs that would be required to report private payer data by up to 70 percent. The idea continues to be explored and final feedback is expected to be included in a June report to Congress.